Historical Origins of the Health Belief Model
Health Education Monographs · 1974
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Health behavior change is our greatest hope for reducing the burden of preventable disease and death around the world. Tobacco use, sedentary lifestyle, unhealthy diet, and alcohol use together account for almost one million deaths each year in the United States alone. Smoking prevalence in the United States has dropped by half since the first Surgeon General’s Report on Smoking and Health was published in 1964, but tobacco use still causes over 400,000 premature deaths each year. The World Health Organization has warned that the worldwide spread of the tobacco epidemic could claim one billion lives by the end of this century. The rising prevalence of childhood obesity could place the United States at risk of raising the first generation of children to live sicker and die younger than their parents, and the spreading epidemic of obesity among children and adults threatens staggering global health and economic tolls. The four leading behavioral risks factors and a great many others (for example, nonadherence to prescribed medical screening and prevention and disease management practices, risky sexual practices, drug use, family and gun violence, worksite and motor vehicle injuries) take disproportionate tolls in low-income and disadvantaged racial and ethnic populations, as well as in low-resource communities across the world. Addressing these behavioral risks and disparities, and the behaviors related to global health threats, such as flu pandemics, water shortages, increasingly harmful sun exposure, and the need to protect the health of the planet itself, will be critical to world health in the twenty-first century. In the past two decades since the publication of the first edition of Health Education and Health Behavior: Theory, Research, and Practice in 1990, there has been extraordinary growth in our knowledge about interventions needed to change health behaviors at both individual and population levels. This progress can be measured in the proliferation of science-based recommendations issued by authoritative evidence review panels, including the U.S. Clinical Preventive Services Task Force, the Centers for Disease Prevention and Control Task Force on Community Preventive Services, and the international Cochrane Collaboration. Today, there are evidence-based clinical practice guidelines for most major behavioral health risks, including tobacco use, unhealthy diet, sedentary lifestyle, risky drinking, and diabetes management. And there are parallel research-based guidelines for the health care system changes and policies needed to assure their delivery and use. New community practice guidelines offer additional evidence-based recommendations for a wide array of population-level school-, worksite-, and community-based programs and public policies to improve vaccination rates and physical activity levels for children and adults, improve diabetes self-management, reduce harmful sun exposure, reduce secondhand smoke exposure, prevent youth tobacco use and help adult smokers quit, reduce workplace and motor vehicle injuries, and curb drunk driving and family and gun violence.
Evaluating the public health impact of health promotion interventions: the RE-AIM framework.
Progress in public health and community-based interventions has been hampered by the lack of a comprehensive evaluation framework appropriate to such programs. Multilevel interventions that incorporate policy, environmental, and individual components should be evaluated with measurements suited to their settings, goals, and purpose. In this commentary, the authors propose a model (termed the RE-AIM model) for evaluating public health interventions that assesses 5 dimensions: reach, efficacy, adoption, implementation, and maintenance. These dimensions occur at multiple levels (e.g., individual, clinic or organization, community) and interact to determine the public health or population-based impact of a program or policy. The authors discuss issues in evaluating each of these dimensions and combining them to determine overall public health impact. Failure to adequately evaluate programs on all 5 dimensions can lead to a waste of resources, discontinuities between stages of research, and failure to improve public health to the limits of our capacity. The authors summarize strengths and limitations of the RE-AIM model and recommend areas for future research and application.